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STATE OF COLORADO <br /> MINED LAND RECLAMATION BOARD <br /> PARTY STATUS WITHDRAWAL FORM <br /> In the matter of File No. M- - , Permit/Permit Amendment Application. <br /> Name of Operator/Applicant and Site: <br /> I hereby withdraw as a party to this matter. _ <br /> I hereby withdraw as a party to this matter and, if the Board holds a hearing, I <br /> wish to address the Board at the formal hearing, if held, as a non-party. <br /> (Please note that if all objecting parties withdraw prior to the date set for the Board's <br /> consideration of the application, the application may be approved by the Office without the <br /> Board holding a hearing. In that event, there will be no opportunity to address the Board on any <br /> issues related to the application. Also, the Board is not obligated to consider any issues raised by <br /> a person or an entity that has withdrawn as a party.) <br /> Regardless of a party status,the Division thoughtfully considers each issue submitted in writing <br /> to the Division and provides a response to those issues within its jurisdiction in the Division's <br /> "Rationale for Recommendation." The Rationale is available to any person by contacting the <br /> Division. For persons who do not wish to become a party or withdraw as a party in this matter, <br /> please contact the Division for information on application status. <br /> ( ) <br /> Printed Name Home Phone# <br /> ( ) <br /> Address Work Phone# <br /> _ ( ) <br /> City, State Zip Code FAX # <br /> E-Mail Address Date <br /> Signature <br /> 12 <br />